ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Establish a plan of care with the client that sets attainable goals. This is because involving the client in setting realistic goals can empower them and increase motivation for rehabilitation. By collaborating with the client, the nurse can address the client's needs and preferences, leading to a more personalized and effective rehabilitation plan. Encouraging the client to actively participate in their care promotes autonomy and fosters a sense of control over their situation.
Other choices are incorrect:
A: Encouraging the client to discuss their feelings is important, but it may not directly address the need for a structured plan of care with attainable goals.
C: Increasing the frequency of physical therapy sessions may be overwhelming for the client and not address the underlying issue of lack of motivation.
D: Allowing the client to set the schedule for rehabilitation may not provide the structure and guidance needed for effective rehabilitation.
Question 2 of 5
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
Correct Answer: B
Rationale: The correct answer is B: Large incisions will be made in the eschar to improve circulation. Escharotomy involves making incisions through the eschar (dead tissue) to relieve constriction and improve circulation in the burned area. By performing escharotomy, blood flow is restored, reducing the risk of compartment syndrome and tissue necrosis.
Choice A is incorrect because skin grafting is a separate procedure done to replace damaged tissue, not part of an escharotomy.
Choice C is incorrect as it describes debridement, not escharotomy.
Choice D is incorrect since escharotomy aims to improve circulation rather than remove the burned area entirely.
Question 3 of 5
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
Correct Answer: B
Rationale: The correct answer is B: Erythrocyte sedimentation rate (ESR). ESR is a common test used to monitor inflammation levels in rheumatoid arthritis (R
A) patients. Aspirin is an anti-inflammatory medication, so monitoring ESR can help assess the effectiveness of the treatment. A decrease in ESR levels indicates a reduction in inflammation, suggesting that the aspirin is working. The other choices (A, C,
D) are not specific to monitoring the effectiveness of aspirin in RA. C-reactive protein and white blood cell count are general markers of inflammation and infection, not specific to RA. Hematocrit measures red blood cell levels, which are not directly related to the effectiveness of aspirin in treating RA.
Question 4 of 5
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Drink 3 L of fluid every day. Adequate fluid intake helps to dilute urine, reducing the concentration of calcium and oxalate, which are the main components of kidney stones. This instruction can help prevent the formation of new stones. Increasing calcium intake (
Choice
A) may actually be beneficial as it can bind with oxalate in the intestines, reducing its absorption and subsequent excretion in the urine. Avoiding foods high in potassium (
Choice
B) is not directly related to preventing calcium oxalate stones. Limiting vitamin C intake (
Choice
D) is not necessary unless the client is taking excessive amounts of vitamin C supplements, which can increase oxalate levels.
Question 5 of 5
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.